Clinical Application Of The Vascular Anatomic Characteristics Surrounding Pancreaticoduodenal Region On Laparoscopic Pancreaticoduodenectomy

Objective: With the help of cadaver dissection and multislice spiral computedtomography angiography, we can do research on the origins, variations, the trend, thebranchs and the communicating branches of the vessels surroundingpancreaticoduodenal region and relationship between the vessels and the surroundingtissue, and discuss surgical techniques of dealing with peripancreatic vessels underlaparoscope, which reduce intraoperative hemorrhage for us to improve the operationon LPD.Methods:(1)4adult cadaver specimens were dissected to observe the adjacentstructure of head of pancreas with vessels, the trend of peripancreatic vessels andrelationships between the vessels and the surrounding tissue.(2) We collect96adultspatients underwent64multislice spiral computed tomography angiography to studythe origins, variations and the branchs and the communicating branches of theperipancreatic vessels utilizing volume rendering and maximum intensity projection.(3) Retrospectively analyse clinical data of13patients doing laparoscopicpancreatoduodenectomy in The Third Affiliated Hospital of Nanchang Universityfrom January2008to August2012，we can study the anatomical features ofperipancreatic blood vessels under laparoscope and the experience of dealing with thevessels under laparoscopic surgery.Results：(1)The relationships between head of pancreas and vessels: commonhepatic artery crossed above the head of pancreas, middle colic artery and vein werebelow it, inferior vena cava、right renal vein crossed behind the head of pancreas,superior mesenteric artery and vein were adjacent to the head of pancreas in the left.(2) The anterior and posterior pancreaticoduodenal arterial arcade mainly suppliedblood to pancreaticoduodenal region.(3)The indirect pancreaticoduodenal bloodsupply artery: the length of common hepatic artery was (17.64±2.70)mm, thevariation rate of hepatic artery was16.67%,and the most common variation in thehepatic arterial anatomy was the replaced right hepatic artery. The length of celiactrunk was (9.96±1.44)mm, the most common variation were celiomesenteric trunk and hepatosplenic, and the variation rate were2.08%、3.13%respectively. The lengthof splenic artery was (62.38±9.30)mm, and the trend of splenic artery has two forms:splenic artery、splenic vein crossed above pancreas and splenic artery was abovesplenic vein, and splenic artery crossed above the pancreas but splenic vein crossedbehind the pancreas; the variation in the splenic artery was hepatosplenic, and thevariation rate was3.13%. The length of gastroduodenal artery was (20.24±3.56)mm，originated from common hepatic artery, and did not find in our study any variants.The length of superior mesenteric artery was (38.96±5.76)mm, it coursed behind thepancreatic body、front the uncinate process where it enters the mesentery; thevariation in the superior mesenteric artery was celiomesenteric, and the variation ratewas2.08%.(4) The direct pancreaticoduodenal blood supply artery: the variation ofposterior superior pancreaticoduodenal artery and dorsal pancreatic artery werecommon, and the variation rate were3.23%、40.00%respectively. Aterior inferiorpancreaticoduodenal artery and posterior inferior pancreaticoduodenal artery canoriginate inferior pancreatcoduodenal artery which directly from the superiormesenteric artery or the first jejunum artery, they could also originate superiormesenteric artery or the first jejunum artery separately. Aterior superiorpancreaticoduodenal artery originated from gastroduodenal artery.(5)Venous arcadesof the pancreatic head: its branches included right gastroepiploic vein、right superiorcolic vein and aterior superior pancreaticoduodenal vein, and the back-flow of Venousarcades of the pancreatic head were three forms: three branches return gastrocolictrunk which reflux to superior mesenteric vein；two branches dry into superiormesenteric vein；two branches belong to the first rendezvous, and then meet the thirdbranch, which dry into superior mesenteric vein. Gastrocolic trunk and its branchesimporting right side of superior mesenteric vein, which located below0.8-2.9cm ofconfluence of superior mesenteric vein and splenic vein.(6) The origins, the trend,and relationship between the vessels and the surrounding tissue of superiormesenteric vein-portal vein-splenic vein were constant, which crossed behind theneck of pancreas. The main length of superior mesenteric vein behind the pancreaswas (39.80±8.30)mm, there were no small blood vessels between the neck ofpancreas and the front of superior mesenteric vein, in addition to small vessels of uncinate process importing the right side of superior mesenteric vein.Conclusions:(1) The indirect pancreaticoduodenal blood supply artery: thevariation rate of the replaced right hepatic artery was the most common variation, weshould pay attention to the trend when cutting off the neck of pancreas inlaparoscopic pancreaticoduodenectomy.(2) The direct pancreaticoduodenal bloodsupply artery: aterior inferior pancreaticoduodenal artery and posterior inferiorpancreaticoduodenal artery could originate superior mesenteric artery or the firstjejunum artery, we should notice their origins when detaching uncinate process fromsuperior mesenteric artery in laparoscopic pancreaticoduodenectomy.(3) There wasthree forms which right gastroepiploic vein、right superior colic vein and ateriorsuperior pancreaticoduodenal vein drying into superior mesenteric vein, we shouldprotect right superior colic vein when cutting off right gastroepiploic vein.(4)Becauseof there were no small blood vessels between the posterior surface of the neck ofpancreas and the front of superior mesenteric vein, we can dissection between theposterior surface of the pancreas and anterior wall of the superior mesenteric veinproceeded from inferior to superior. At the same time, gastrocolic trunk and itsbranches drying into the right side of superior mesenteric vein were constant. Whendetaching the space between the posterior surface of the pancreas and anterior wall ofthe superior mesenteric vein, we should pay attention to gastrocolic trunk, and do notdamage splenic artery and splenic artery. In a word: The matching and distributionrelation of the blood vessels of the pancreas head should be mastered. It is beneficialto reduce intraoperative bleeding when doing laparoscopic pancreaticoduodenectomyand improve operation quality.